Coroners Act 1996 [Section 26(1)] Western Australia
RREECCOORRDD OOFF IINNVVEESSTTIIGGAATTIIOONN IINNTTOO DDEEAATTHH Ref: 43/17 I, Sarah Helen Linton, Coroner, having investigated the suspected death of Rohan Daniel WILSON with an inquest held at the Perth Coroner’s Court, Court 51, CLC Building, 501 Hay Street, Perth on 15 November 2017 find that the death of Rohan Daniel WILSON has been established beyond all reasonable doubt and that the identity of the deceased person was Rohan Daniel WILSON and that death occurred on or about 15 June 2016 at sea approximately 30 nautical miles from the coastline of Perth, in the vicinity of Mindarie Marina, as a result of an unascertained cause in the following circumstances: Counsel Appearing: Sgt L Houisaux assisting the Coroner.
TABLE OF CONTENTS Inquest into the death of Rohan Daniel WILSON (723/2016) 1
INTRODUCTION
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Rohan Wilson was last seen on the morning of 15 June 2016 as he prepared to go fishing in his boat in the Indian Ocean off the coast of Mindarie. He contacted his wife by telephone during the day to tell her about a fish he had caught. That was the last time Mr Wilson made contact with any of his family and he was never seen or heard from by them again.
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That evening Mr Wilson’s wife reported him missing to police. Search operations formally commenced that evening and extensive land, sea and air search continued over the following days. Some items of debris were found in the search area that were thought to have possibly come from Mr Wilson’s boat but no sign of Mr Wilson or his boat was found.
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Police officers from the Water Police notified the Office of the State Coroner of the circumstances of the disappearance of Mr Wilson in June 2016 and indicated that a final investigation report for the Coroner would be prepared in due course.
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At the end of June 2016 Mr Wilson’s family contacted the Coroner’s Court of Western Australia and indicated that it was the family’s opinion that Mr Wilson had died. They asked the State Coroner to investigate Mr Wilson’s disappearance and consider holding an inquest to determine whether he was deceased.
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The State Coroner sought further information from the WA Police, which was provided on 24 August 2017 in the form of a report prepared by Sergeant Andrew Abel of the Clarkson Police. Sergeant Abel indicated that the evidence obtained in the investigation supported the conclusion that Mr Wilson had died at sea in June 2016.
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On the basis of the information provided the State Coroner determined that pursuant to s 23 of the Coroners Act 1996 (WA) there was reasonable cause to suspect that Mr Wilson had died and that the suspected death should be investigated. Following that direction it is a requirement that a coroner must hold an inquest into the circumstances of the suspected death.
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I held an inquest at the Perth Coroner’s Court on 15 November 2017. The documentary evidence comprised Sergeant Abel’s report of the police investigation into the disappearance of Mr Wilson, which included a comprehensive report prepared by Senior Constable Paul Cranshaw of Water Police as to the search that was conducted for Mr Wilson and an investigation report prepared by the Department of Transport.1 Sergeant Abel was also called to give oral evidence at the inquest.
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At the conclusion of the inquest I indicated to Mr Wilson’s family that I was satisfied beyond reasonable doubt that Mr Wilson had died but that I would have to give further consideration as to what conclusions I could reach about the circumstances of his death, given the limited information available.
1 Exhibit 1.
Inquest into the death of Rohan Daniel WILSON (723/2016) 2
BACKGROUND
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Mr Wilson was 38 years old in June 2016. He was married with two young children. He worked as a Production Chemist at Barrow Island on a ‘fly in, fly out’ basis.2 He enjoyed his work.3
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Mr Wilson owned a 6.4 metre registered power boat, which was named ‘Hot Gossip’. It had an inboard petrol motor.4 Fig 3. 1 -Photo of vessel 61802 'Hot Gossip'
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Mr Wilson was an experienced boat handler, having owned his vessel for 12 or 13 years. Mr Wilson had the boat regularly serviced but it was thought he hadn’t been out in it for possibly two or three months prior to 15 June 2016.
Mr Wilson was described as very safety conscious and had a marine radio and a full suite of safety equipment on board.5 He was also described as meticulous about maintenance of his vessel.6
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Mr Wilson was very used to navigating a significant distance offshore to fish in deep water. He often went fishing alone. He typically prepared his vessel and gear the night before and then would depart home at about 8.00 am in the morning so that he could depart from the boat ramp by 8.30 am.7
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At the time he went missing Mr Wilson’s family indicated he had no known medical conditions and was reasonably fit for his age. He had no known issues with drugs or alcohol. He was able to swim.8
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Mr Wilson was happily married and had a good home life. On the morning Mr Wilson was last seen alive Mr Wilson’s wife described him as in good spirits.9 2 Exhibit 1, Tab 3, p. 12.
3 Exhibit 1, Tab 4 [23].
4 Exhibit 1, Tab 3, p. 6.
5 Exhibit 1, Tab 3, pp. 6 and 12 and Tab 4.
6 T 8.
7 Exhibit 1, Tab 3, pp. 6 and 12.
8 Exhibit 1, Tab 3, p. 12 and Tab 4.
Inquest into the death of Rohan Daniel WILSON (723/2016) 3
EVENTS ON 15 JUNE 2016
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Mr Wilson was not in the habit of logging his boating trips with Volunteer Marine Rescue groups. However, he did follow the recommended practice of logging a voyage plan by leaving a detailed note for his wife about his planned voyage. Mr Wilson’s note read as follows: 15/6/2016 Mindarie 8.30 am 20 – 30 mile WNW Fishing 1 person 240L Fuel Return by 8pm.10
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The benefit of Mr Wilson leaving such a detailed note was that it meant his wife was able to establish that he was missing at a relatively early stage and provide relevant information to Water Police to narrow their search area. It is a practice encouraged by the Department of Transport as part of the ‘Recreational Skippers Ticket’ training for those reasons, although it is suggested that logging on and off with a Volunteer Marine Rescue Group or Water Police by radio is the best option.11
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Although the note indicated Mr Wilson left in the morning at 8.30 am it seems he prepared that note at night and left later the next morning than expected.12 The police investigation found evidence that Mr Wilson obtained fuel from the Caltex petrol station in Clarkson, at which time he was alone, before launching his boat at 11.20 am at the Mindarie Marina boat ramp.
Mr Wilson’s car and trailer were located by the police at the marina, indicating he had not returned to that location after launching his boat that morning.13
- At 2.45 pm Mr Wilson’s wife received a text message from Mr Wilson stating that he had “caught a 92cm Dewie”14 (referring to a Dhufish). This was the last time Mrs Wilson heard from her husband.15 When he had not returned by 8.00 pm that evening, as planned, Mrs Wilson made a number of attempts to contact Mr Wilson on his mobile telephone, without success.
Mrs Wilson then contacted the Whitfords Volunteer Marine Rescue Group (Whitfords VMR) and the Water Police to advise that Mr Wilson was missing.16 9 Exhibit 1, Tab 4.
10 Exhibit 1, Tab 3, p. 7.
11 https://www.transport.wa.gov.au/mediaFiles/marine/MAC_P_RST_Workbook7.pdf, p. 68.
12 Exhibit 1, Tab 4 [10].
13 Exhibit 1, Tab 2, pp. 2 – 3.
14 Exhibit 1, Tab 4 [15].
15 Exhibit 1, Tab 3, p. 7.
16 Exhibit 1, Tabs 2 and 3 and 4.
Inquest into the death of Rohan Daniel WILSON (723/2016) 4
THE SEARCH
- Water Police officer Senior Constable Peter Murphy was on duty as the Search and Rescue Mission Controller (SMC) at Water Police at the time the call was received at around 9.30 pm. Senior Constable Murphy initiated an immediate response, commencing a marine search operation.17 Senior Constable Murphy instructed the Whitfords VMR to broadcast radio Securité messages requesting boaters to keep a look out for the vessel. Senior Constable Murphy also:
• contacted the Joint Rescue Coordination Centre (JRCC) in Canberra and confirmed that there were no emergency beacon activations (EPIRBS) which had yet to be resolved;
• tasked the WA Police helicopter ‘Polair 61’ to search a track line from Mindarie Marina west north-west to Direction Bank;
• contacted Fremantle Port operations tower to check vessel movements in the area; and
• tasked local police to check the car park at Mindarie Marina to check and confirm whether Mr Wilson’s vehicle and boat trailer were still parked in the car park. They attended and confirmed that the car and trailer were in situ.18
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An area of interest was located that was approximately in the direction and at similar range to the details indicated in Mr Wilson’s note he had left that morning. The area showed sea bed consistent with the type of waters commonly fished by Mr Wilson and hence was nominated as an area of interest. Polair 61 was tasked to complete an expanding square search over this area. This was completed and the crew reported sighting several light sources and vessels but none matching the description of Mr Wilson’s vessel.19 A Whitfords VMR vessel also conducted an expanding square search commencing at the centre of the identified area but no sign of Mr Wilson was found.20
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After searching the area the helicopter then followed a track line back to shore north of the original line to cover the possibility that Mr Wilson had taken a more direct track back to shore.21
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These initial searches by Polair 61 and the Whitfords VMR were completed during the hours of darkness overnight on 15 June 2016 into the early hours of 16 June 2016.22
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The following morning Acting Sergeant Paul Cranshaw took over the role of SMC from Senior Constable Murphy. He then made contact with JRCC in Canberra and it was agreed Water Police would retain coordination of the search operation. JRCC sourced a total of 6 aircraft to execute an air search 17 Exhibit 1, Tab 3, pp. 5 and 8.
18 Exhibit 1, Tab 3, p. 8.
19 Exhibit 1, Tab 3, p. 9.
20 Exhibit 1, Tab 3, p. 10.
21 Exhibit 1, Tab 3, p. 10.
22 Exhibit 1, Tab 3, p. 10.
Inquest into the death of Rohan Daniel WILSON (723/2016) 5
and a total of 9 search and rescue marine vessels were also sourced to assist with the marine search.23
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Various possible scenarios were discussed within the incident management team, including that the possibility that Mr Wilson had fallen overboard or had a medical event, as well as the vessel potentially having suffered a catastrophic event. WA Police used SARMAP, a computer system designed to assist with the prediction of movement of objects in the water, to assist in predicting a drift line if the vessel was disabled and adrift, as well as if there was a person in the water or vessel related debris in the water.24
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Water Police also sought expert medical advice from Dr Paul Luckin as to the ‘time frame of survival’ for Mr Wilson. Dr Luckin’s advice was that if Mr Wilson was in the water rather than in his boat, and not wearing a lifejacket, there was very little chance that he would still be alive by the afternoon of 16 June 2016. If he was wearing a lifejacket, there was very little chance Mr Wilson would survive beyond the end of daylight on 16 June 2016 and if he was in the water resting on the upturned hull of the vessel, he would be unlikely to survive the night. The only possible chance that Mr Wilson would survive into the following day was if he was still inside the floating vessel.25
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Mrs Wilson advised that the deceased was not known to wear a lifejacket at any time while on the water.26
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A search was conducted from 7.00 am to 6.30 pm on 16 June 2016 with no evidence found of Mr Wilson or his vessel, despite the search conditions being good and a high probability of detection being achieved.27
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Officers from Clarkson Police Station conducted a land search on the coastline and other land based searches, including of Mr Wilson’s car, which indicated that he had gone to sea much later than the initial 8.30 am indicated in his note (based upon the fuel receipt), which was confirmed by the CCTV footage at the service station and the marina.28
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Enquiries were made with Telstra in relation to Mr Wilson’s telephone records, which showed Mr Wilson’s phone signal had last been connected to cell towers in Guilderton and Two Rocks, the last time at 3.31 pm off Two Rocks tower. The information obtained suggested that the vessel was still operating normally at that time and Water Police officers concluded that Mr Wilson was probably just repositioning from one fishing spot to another around this time.29 The information also assisted in identifying a likely location to indicate where a stricken vessel may have drifted to later, which was still within the original search area identified through the Water Police SARMAP prediction.30 23 Exhibit 1, Tab 3, p. 12.
24 Exhibit 1, Tab 3, p. 13.
25 Exhibit 1, Tab 3, p. 15.
26 Exhibit 1, Tab 14, p. 4.
27 Exhibit 1, Tab 3, p. 16.
28 Exhibit 1, Tab 3, p. 16.
29 Exhibit 1, Tab 3, pp. 19 – 20.
30 Exhibit 1, Tab 3, p. 19 – 20.
Inquest into the death of Rohan Daniel WILSON (723/2016) 6
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After the completion of search operations on 16 June 2016 a Water Police vessel on evening shift was tasked to attend the coordinates of the deceased’s last telephone connections and conducted a 2 nautical mile search over the area, including a RADAR search and aural search (in which they switch off all devices and call out to the missing person and listen carefully for any response). No contact was made with Mr Wilson.31
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By the end of the day on 16 June 2016 the Water Police had drawn the following conclusions from all of the information that had been obtained by that stage:
• Mr Wilson’s telephone had been offline since 3.31 pm on 15 June 2016, and had most likely initially gone offline simply due to him travelling beyond the range of the nearest mobile telephone towers;
• Mr Wilson was well equipped and if he had simply broken down he would have activated his distress beacon by that time;
• If Mr Wilson had succumbed to a medical episode that had rendered him unable to activate his beacon or otherwise summon assistance, he should still have been located drifting by search units unless he was still motoring at the time the event occurred;
• If the vessel had sunk within the search area, previous experience suggested that there would likely be numerous floating items of debris from the vessel that would have been found;
• However, if the vessel had suffered a sudden fire or explosion before sinking, it would mean that less debris would be found as it may have burnt or sunk. This theory remained a significant possibility.
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On 17 June 2016 further searching was conducted after the SARMAP had been utilised to provide further drift prediction modelling. Due to the overall effects of drift over time, the overall search area was moving further offshore, which presented challenges with communications as well as fatigue and seasickness due to the sea state. Some of the areas were partially searched by a Police helicopter for those reasons.32
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During search operations on 17 June 2016 vessel crews located and collected various items of flotsam and debris. Most were subsequently discounted as being related to Mr Wilson but of note was a small piece of white plastic located by one crew in the southern end of search area 2. It was noted to be in similar shape and appearance to a white plastic ice-box or Esky seen in photographs of the vessel provided by Mr Wilson’s wife. The location of the burnt plastic piece was concurrent with drift modelling from the last known position of Mr Wilson’s vessel.
31 Exhibit 1, Tab 3, p. 20.
32 Exhibit 1, Tab 3, p. 23.
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Fig 6.4 - Police photograph of burnt piece of plastic located in search area 2 by VMR vessel Sea Guardian II Fig 6. 5 - Photograph supplied by Melissa WILSON showing plastic icebox carried by her husband on the missing vessel
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The finding of the burnt plastic piece significantly increased Senior Constable Cranshaw’s suspicion of the possibility that the missing vessel had suffered either a catastrophic fire or an explosion.
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Even though the time frame of survival had expired, further searching was planned for 18 June 2015, with a new search area re-calculated based on SARMAP drift models. Marine vessels were deployed to the location that the burnt plastic had been located. During this search some small items of Inquest into the death of Rohan Daniel WILSON (723/2016) 8
debris were found but they were examined and thought to be more likely to be fragments of cray pot floats that had been in the water for some time, rather than items from Mr Wilson’s boat. The search concluded at 3.00 pm that day.33
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After the four days of the search operation the probability of detection, being the probability of the search object being detected assuming it was in the areas that were searched, was calculated. The cumulative probability of detection (POD), based on the repeated searches, was found to be 99% over the areas searched (noting that it is generally regarded as impossible to achieve a POD of 100% in practice due to human and environmental factors).34
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In conclusion, despite the extensive search operation, only a very few small debris items were located and there was no sign of the missing vessel ‘Hot Gossip’ nor Mr Wilson. The area where Mr Wilson was last known to be fishing was remote, increasing the likelihood that he would not be found.35
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The search operation had attracted significant media coverage, which resulted in police receiving numerous calls from members of the public over the following weeks who had located items of possible interest on the beaches of Perth’s northern suburbs. Based upon the information provided many of the items were seized and examined. After conducting enquiries with family members or relevant experts none of the items could be conclusively linked to the missing vessel,36 although there was a strong inference that the burnt piece of plastic came from the white esky on board.37
OPINION OF INVESTIGATORS
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Based upon all the available evidence, Senior Constable Cranshaw formed the opinion that the most likely possible scenario is that Mr Wilson’s boat suffered a sudden on-board fire. This could have occurred in a number of possible scenarios, although in Senior Constable Cranshaw’s opinion the most likely one would be a build-up of fuel fumes in the engine compartment being ignited by a spark from some on-board electrical equipment such as a starter motor, bilge float switch or electric fishing reel connections.
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Due to the possibility and dangers of fuel fumes, vessels powered by inboard petrol motors are recommended, but not required, to be fitted with a ‘bilge blower’. This is a ducted electric fan arrangement, which vents any fumes out of the engine compartment and draws fresh air into the compartment instead, thus negating the risk of fire or explosions from fumes. Mrs Wilson reported that she thought the vessel ‘Hot Gossip’ was fitted with a bilge blower, although this could not be confirmed.38 33 Exhibit 1, Tab 3, p. 25.
34 Exhibit 1, Tab 3, p. 26.
35 T 7.
36 Exhibit 1, Tab 3,
37 T 9.
38 Exhibit 1, Tab 3, p. 29.
Inquest into the death of Rohan Daniel WILSON (723/2016) 9
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The previous owner of the vessel was spoken to as part of the Department of Transport investigation. The former owner indicated that the engine bay had vented petrol fumes and other exhaust gases by way of a blower (fan) fitted under the engine which discharged off any gases through a pipe arrangement.39
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The Department of Transport investigation report indicated that recreational vessel statistics between 1 January 2005 and 30 June 2016 provide a total number of 49 incidents resulting from a fire or explosion (only 1 incident of explosion). Of these incidents only a small number were directly attributed to fires from petrol fumes, although in the majority of cases investigators were unable to identify a cause.40
HAS DEATH BEEN ESTABLISHED?
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Mr Wilson has made no contact with his family since 15 June 2016. He was a happy and committed husband and father and failure to contact his family is out of character for him.41
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The WA Police have conducted a number of ‘proof of life’ checks with various businesses, government agencies and financial institutions and it has been established that Mr Wilson has not accessed his bank account, not used Medicare or PBS services, not been in contact with police in any state or come to the attention of the Department of Immigration.42
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The police have found no evidence of criminality in relation to Mr Wilson’s disappearance.43 No one has come forward to suggest any reason why Mr Wilson might want to suddenly disappear.
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All possible investigative avenues available to the WA Police have been exhausted in attempting to locate Mr Wilson. Sergeant Abel confirmed at the inquest that the results of the police investigation support the conclusion that Mr Wilson died at sea sometime on or about 15 June 2016. Mr Wilson’s family have indicated to Counsel Assisting that they accept this conclusion.
This inquest is really about giving the family some final, official confirmation of what they have reluctantly already come to accept.
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Based on all of the evidence I am satisfied beyond reasonable doubt that Mr Wilson is deceased and I so find.
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Having concluded that Mr Wilson has died, it is clear from the circumstances surrounding his death that his death is a reportable death under the terms of the Coroner’s Act, and it is my obligation to try to determine the cause of death and how the death occurred, if possible.
39 Exhibit 1, Tab 14, p. 4.
40 Exhibit 1, Tab 14, p. 7.
41 Exhibit 1, Tab 2.
42 Exhibit 1, Tab 2.
43 Exhibit 1, Tab 2.
Inquest into the death of Rohan Daniel WILSON (723/2016) 10
DATE, PLACE, CAUSE AND MANNER OF DEATH
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I am satisfied that Mr Wilson has died, but as to when, where and how he died, there is limited information on which to base a finding.
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The evidence before me supports the conclusion that there was a catastrophic event onboard ‘Hot Gossip’ that caused the vessel to sink suddenly, resulting in little evidence of debris for searchers to locate. This is supported by the conclusion that Mr Wilson was unable to set off his EPIRB and did not use his mobile telephone to try to contact anyone.
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If Mr Wilson survived this catastrophic event, he would have gone into the water most likely without a lifejacket on, as he was not known to wear one as a matter of course and would have been unlikely to have been able to obtain one in time. His time for survival in those circumstances, particularly if he was already injured, was relatively short based upon the evidence of Dr Luckin.
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Based upon all of the evidence before me, I am satisfied that Mr Wilson died sometime on or about 15 June 2016.
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As Mr Wilson’s remains have not been discovered, his cause of death is difficult to determine. Police investigators have suggested scenarios consistent with an accidental death, either as a result of the fire or explosion, or possibly immersion after going into the water. In the circumstances, I am unable to reach a conclusion as to the cause of death, and it must remain unascertained for the purposes of registration.
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The evidence before me supports the conclusion that there was a catastrophic event leading up to Mr Wilson’s death. It follows that I make finding that the death occurred by way of accident.
CONCLUSION
- Mr Wilson was an experienced fisherman who was in the habit of going out alone for a day’s fishing in his boat, ‘Hot Gossip’. On 15 June 2016 he was in good spirits and looking forward to a day of fishing when he left his home.
He was seen to launch his boat at Mindarie Marina later that morning and sent his wife a text in the early afternoon indicating that the fishing was good. When Mr Wilson did not return home from his fishing trip that night he was reported missing and a search was immediately commenced. Despite the search continuing over a number of days no definite sign of Mr Wilson or his boat was ever found. However, the general evidence, including some debris found, suggests that a catastrophic fire or explosion occurred on the boat sometime after 3.30 pm that day that resulted in the boat sinking into Inquest into the death of Rohan Daniel WILSON (723/2016) 11
the ocean almost without a trace. I have found that Mr Wilson died as a result of that catastrophic event.
S H Linton Coroner 23 November 2017 Inquest into the death of Rohan Daniel WILSON (723/2016) 12